WHAT'S UP DOC? Chronic Epstein Barr

Tuesday

Apr 4, 2017 at 5:11 PMApr 4, 2017 at 5:11 PM

By Dr. Jeff Hersh/Daily News Correspondent

Q: Is there a such thing as chronic mononucleosis?

A: Mononucleosis (mono for short, and sometimes referred to as the kissing disease) is a viral illness caused by the Epstein-Barr virus (EBV, although similar "mono-like" illnesses can be caused by other viruses).

Mono is an infectious disease that can be spread from person to person via exchange of body fluids. These fluids include saliva (hence the moniker "kissing disease" although sharing a drink, utensils or saliva in any other way can also spread the virus), mucus (so it can be spread from coughs or sneezes) and even tears. The EBV may be present in these fluids for months or even years after someone is initially infected; therefore, the virus can be passed on from person to person for quite a long time. However, exposure to someone shedding the virus does not always mean the exposed person will develop mono, or even that they will become infected with EBV.

Mono is a very common condition; about one in 2,000 people get symptomatic illness from it every year, most commonly between ages 10 and 25. However, the infectious rate of this virus is much more than this suggests. Overall, antibody testing shows that over 95 percent of Americans have been infected with EBV by the time they reach adulthood. Most infections occur during childhood and have no or mild symptoms (so their illness may be confused with a common cold or other viral syndrome), so they are not aware that they have been infected with EBV.

The classic symptoms of mono commonly occur in adolescents and young adults, and include fever (often 101 degrees Fahrenheit or higher), sore throat, fatigue and swollen glands. Other common symptoms include swollen tonsils, headache, elevated liver function tests and/or body ache. An enlarged spleen develops in about half of symptomatic patients. Rare symptoms include neurologic symptoms (such as facial nerve palsies), heart or other organ involvement. A rash is very common in mono patients if they are unnecessarily treated with ampicillin (usually for presumed strep throat, it is not beneficial for EBV).

Unlike the common cold which usually lasts just days to a week or so, some of the symptoms of mono can last quite a while. The swollen glands typically last two to three weeks. The fatigue often lasts a couple of months, although in over 10 percent of patients it lasts six months or longer. The enlarged spleen typically resolves within three weeks.

Life threatening complications of mono are rare, and can include airway compromise from extremely enlarged tonsils and/or a spontaneously ruptured spleen (which occurs in about one in 1,000 patients). Other complications may include neurological disease, hepatitis (inflammation of the liver) or problems with their blood count (usually low blood counts due to compromise of bone marrow production of blood cells).

Very rarely (in the United States, this seems to be a bit more common in Asia and South America), a patient will develop chronic active EBV (CAEBV). Patients diagnosed with CAEBV usually have extremely high levels of DNA from the EBV and their hematological system produces too many T-cells (a type of white blood cell). These patients have symptoms similar in character to those seen with mono as noted above, but much more severe and very persistent (hence the term chronic). CAEBV has a high mortality, whether from liver failure, lymphoma (that may develop as a complication of the infection), bleeding/"opportunistic" infections (that may occur due to the compromise in red/white cell production respectively) or other causes.

It is not clear why some patients develop CAEBV, although some studies have questioned whether mutations in the EBV in these patients may be a contributing factor, or if it is due to some genetic factors in the patient themselves (making them more susceptible).

The best treatment regimen for CAEBV patients is not known. Trials of antiviral medications have had limited success in some studies. Treatment with immunosuppressive agents have been shown to improve symptoms in some patients but not to be curative. Several cases studies have been reported showing successful treatment with bone marrow transplant, but no large-scale studies have yet confirmed this.